Naturopathic physicians in Oregon — those who practice natural medicine and favor herbs and diet changes over pharmaceutical medications — have for years been trying to convince insurance companies to cover their services at the same level as conventional physicians.

When the Affordable Care Act became law, they thought its provider nondiscrimination clause, which says insurers must cover providers acting within the scope of their license under state law equally, would finally set things straight. But when the provision took effect on Jan. 1, most policies stayed the same.

Now, they’re turning their sights to a proposal that’s being crafted in time for the 2015 legislative session. The Oregon Insurance Division is preparing rules that would ensure insurance policies have adequate provider networks, and naturopathic physicians believe that will include them, too.

“Inherently, if you can’t discriminate against provider types providing a service, then it means you have to have at least some number of all different provider types in your network,” said Laura Culberson Farr, executive director of the Oregon Association of Naturopathic Physicians. “If you don’t, you’re discriminating against certain provider types.”

For its part, the Insurance Division isn’t taking an official position on how the provider nondiscrimination clause applies to naturopathic physicians. Lisa Morawski, a spokeswoman for the division, wrote in an email that providers can file complaints with the division if they feel they’re being discriminated against, and officials will look at that case’s unique circumstances. She said the federal government is expected to issue guidelines on the subject in the coming months.

Oregon is among the 17 states plus Washington, D.C., that licenses naturopathic providers.

But not everyone thinks it’s a good idea for naturopaths to serve as primary care physicians. It would essentially allow people to see a naturopathic physician for their annual primary care visits — which most insurers don’t currently allow — and some say naturopathic physicians don’t have the same level of training as medical doctors to be able to diagnose and treat serious health issues.

What’s the difference?

Becoming a medical physician requires at least three more years of medical training compared with a naturopathic physician.

That’s because, although they each must undergo four years of medical school, generally with the first two years studying science and the final two working in clinical settings under supervision, medical physicians are required to serve in residencies before they can become licensed. A residency is a three- to seven-year stint working in a medical setting under the supervision of senior physicians.

Family practice physicians, those who most commonly perform the primary care duties that naturopaths also provide, spend an average of three years in residencies. Naturopathic physicians, by contrast, are not required to do residencies.

Reid Blackwelder, a family physician and president of the American Academy of Family Physicians, said his research has shown that family physicians have received an average of 21,000 hours of medical education, while naturopathic physicians have received about 6,400 hours.

Naturopathic physicians, on the other hand, tend to emphasize the similarities between their schooling and that of medical physicians.

“Everyone who is a naturopathic doctor has been through a real similar routine in terms of education in that we graduated from four-year university, did a lot of pre-med requirements, et cetera, and then went on to at least four years of naturopathic medical school and sometimes longer,” said Joshua Phillips, a naturopathic physician at the Hawthorn Healing Arts Center in Bend.

A whole-person approach

But naturopathic physicians are quick to highlight the differences, too. For Phillips, naturopathy represents a departure in philosophy from traditional medicine. Whereas medical physicians look to suppress symptoms when they come up, naturopathic physicians strive to treat the underlying cause of those symptoms, he said. Naturopathy is a more personal approach to health care, one that emphasizes a broader range of therapies — botanicals, nutrition, acupuncture, Chinese medicine and homeopathy — rather than pharmaceutical medications as the first line of defense, Phillips said.

Although naturopathic physicians can prescribe pharmaceuticals, most regard it as a last resort. Phillips said he wants to promote the body’s natural healing process, and medications — blood pressure medications, for example — only manage physiology.

“As soon as you stop a blood pressure medication, your blood pressure is going to come right back up, probably even higher than it was,” he said. “So you’ve not done anything to improve somebody’s health. It’s not a cure. So I guess just sort of the ideal of hoping we can work toward a cure with somebody. To really facilitate a healing process, which means that when you stop taking the therapy, whatever it is, that you’re better, which doesn’t happen with pharmaceuticals.”

Other naturopathic physicians offered similar perspectives.

Wendy Weintrob, a naturopathic physician with Glow Acupuncture and Naturopathic Medicine in Bend, said if patients want statins or high blood pressure medications, she refers them elsewhere. In fact, rather than performing primary care, she said she specializes in treating conditions like anxiety, depression and digestion issues.

“I try to do everything else first because the first tenet of naturopathic medicine is do no harm,” she said. “That is not the case with most drugs. You hear on television the list of side effects. It’s not a secret.”

Natural and herbal products such as St. John’s wort are drugs, too, and can have side effects and dangerous interactions with other drugs, Blackwelder said.

As Culberson Farr put it, “Naturopathic doctors are always going to try to get to the root of whatever might be causing the disease rather than treat the symptoms the patient presents in the clinic.”

Blackwelder said he’s heard that argument from naturopathic physicians before. That’s exactly what family medicine physicians do, he said: They look at the whole person, not only their body, but their social structure and their community.

Naturopathic physicians also say they’re able to spend more time with patients, which allows for the deeper dive into their conditions. Phillips, for example, says he sets aside 45 minutes to an hour for new patients, and follow-ups are a half-hour to 45 minutes.

Skeptics point to risks

Mark Crislip, who has worked as an infectious disease physician in Portland for 30 years, said he agrees medical physicians generally cannot spend as much time with their patients, but he does not think that means naturopathic physicians can take their place.

Crislip, the president and founder of the Society for Science-based Medicine, is a vocal critic of naturopathic medicine. He said his interest in the subject began decades ago when he was asked to see a 24-year-old patient with gangrene, an unusual diagnosis for a young person. The patient had originally been diagnosed with a sarcoma of the leg, but rather than having surgery, she saw a naturopathic physician who treated her with alkaline therapy, a method designed to lower the body’s acidity and create an environment cancer cells cannot thrive in. The cancer progressed, but the physician told her that meant her body was fighting the cancer. Eventually, the patient’s leg rotted until it eroded into a major blood vessel and the patient died, Crislip said.

“Her cancer could have been cured with an amputation,” he said.

Although naturopathic physicians insist they have the training to recognize serious conditions and refer their primary care patients to specialists just as any other primary care physician would, Crislip said he doesn’t believe they know what to look for. He said much of being good at medicine means being able to recognize unusual cases when they walk through the door, a skill that simply takes time to develop. In February 2014, for example, a Portland woman died of endocarditis, or inflammation of the heart chambers and valves. She had been seeing naturopathic physicians for months before her death.

“I’ve never seen anybody in all my career who is allowed to die of progressive endocarditis, which is a disease that takes six to nine months to kill people,” Crislip said. “That’s what used to happen in the era before we had antibiotics. That’s the kind of stuff that can happen when you have people who are untrained to recognize real diseases. That’s exactly the kind of outcomes you get.”

‘It didn’t come natural’

Most insurance companies that sell policies in Oregon do not cover naturopathic physicians as primary care providers, and instead of classifying them under the major medical sections of their plans, include them in smaller alternative or complementary sections that tend to have coverage limits of around $2,000 annually.

Moda Health, for example, reimburses for naturopathic services, but does not cover naturopathic physicians as primary care providers because they don’t meet the company’s requirements for the designation, which include having admitting privileges to a hospital and having another provider in their office available to treat patients in case their primary care provider is out of the office. Jonathan Nicholas, a Moda spokesman, wrote in an email that the company is working to potentially change those rules.

Regence BlueCross BlueShield of Oregon and Oregon’s Health CO-OP have each implemented the provider nondiscrimination clause into their policies and reimburse naturopathic physicians as primary care providers. PacificSource Health Plans reimburses naturopathic providers in the same manner as other providers, but does not designate them as primary care providers.

Some of Oregon’s coordinated care organizations, the groups responsible for doling out Medicaid funding in Oregon, allow naturopathic physicians to serve as primary care providers. While Central Oregon’s CCO does not, a handful of CCOs do, including HealthShare Oregon in the Portland metro area and Jackson Care Connect in Jackson County, according to the OANP.

Ralph Prows, the CEO of Oregon’s Health CO-OP, said that as a cooperative, his company is supposed to create its policies around the services its members want. At each meeting the company held with members, he said people would say they wanted to see naturopathic physicians, arguing that they felt more supported by naturopathic physicians and that those providers spent more time with them, counseling them on lifestyle issues like exercise and smoking.

Prows, a medical physician who was trained as an internist, said he was skeptical at first, but knew he had to research naturopathic medicine to determine whether the CO-OP would cover it.

“What this really did for me was take off my blinders and open my eyes and say, ‘I have to explore this option with an open mind,’” he said. “Plenty of my fellow Oregonians have done that and they’ve reached a conclusion.”

After doing some reflection, Prows said he realized that traditional physicians spend too much time focusing on the “disease du jour” and not enough on encouraging healthy behaviors. The CO-OP covers naturopathic physicians as primary care providers. The company has between 80 and 100 naturopathic physicians in its policy networks, Prows said. He declined to say how many clients have chosen naturopathic physicians as their primary care providers, but said they’ve been popular.